DMB

I find myself in partial agreement with both sides on this issue.

The big head problem means that we probably give birth to babies with the maximum size of head that can be safely delivered, which may well explain why the human baby is born rather more helpless than a chimpanzee and the brain goes on doing so much development immediately after birth. Any time you are knocking up against an evolutionary limit in this way means that there will be resulting casualties.

Maternal and infant mortality and morbidity were high in all pre-modern countries, just as they are in less developed countries. Some of the problems arise from poor nutrition and particularly from too early pregnancy or too many pregnancies. Some deaths are the result of unsafe abortions.

In the developed world we now enjoy high nutritional standards, discouragement of very early pregnancy, access to contraception and medical abortion and high levels of medical care, all of which contribute to safer pregnancies and birth.

But, there is no doubt that there are fashions in medical practice and certain procedures are carried out without necessarily having clinical trials or other scientific evidence to support them. I haven't looked this up, but I believe that according to the WHO, caesarians can save lives or injury in about 8% of births. If the rate is notably higher than that, it would suggest that some of these interventions are not mediaclly justified. Furthermore, caesarians are inherently more risky than vaginal deliveries, so it's not a good thing to have an elective one if you simply don't like the idea of giving birth the natural way.

I personally am very glad that effective medical intervention is possible. When I had my first child, I developed pre-eclampsia towards the end of the pregnancy and had to have the birth induced both for my own sake and for the sake of the baby. I was lucky enough to have a fast and natural labour for my second child. With the first one I had an episiotomy, which took a long time to heal and left me with various problems; with the second one I tore and healed so well that some of the problems of the first birth were reversed.

IMO there is no one-size-fits-all solution for childbirth. The desirable goal is an uncomplicated vaginal delivery. If breathing exercises, yoga, etc., help you to mange without any form of anaesthetic, well and good, but you are not a failure if you need help with the pain or if the birth requires a caesarian. Some women find the pain of childbirth manageable; others find it unbearable. Men are lucky that they don't have to experience it!

Mark_Chid

Crap. And not only crap, DANGEROUS crap. Modern obstetric science has reduced infant and maternal mortality tenfold (at least).

You have a choice. Believe the opinion of those that sweat blood studying the subject for the best part of a decade in order to qualify, or believe some bozo who makes it up as they go along.

If you choose to have a child without ANY medical intervention you stand a reasoanable chance of losing your child AND your wife. For the sake of both of them, wake up!

alek0

His wife and child can also be endanegred by unnecessary medical interventions. I don't think that anyone is arguing against medical interventions in childbirth per se. Necessary ones are saving lives. Unnecessary ones, such as unnecessary inductions, ceseareans and episiotomies, are causing harm.

I would really like to hear you guys who are so much in favour of medical interventions to justify high cesearean rate and instrumental delivery rate. Also please explain usefullness of episiotomy "to prevent tearing".

elwoodblues

It's my understanding that a surgical incision in muscle tissue will heal far better than a _tear_ in that tissue. I may be totally off base here, though.

Coragyps

One tangential issue to this thread that truly pisses me off is the frequency of C-sections in hospitals with a high ratio of mothers on welfare or other public assistance. It's been a few years since I read a study on such, but the percentage of Caesarians was astoundingly high in some inner-city US hospitals, apparently only because the doctor (and hospital) gets a much better paycheck from the state for the more complicated procedure. I could guess that the current bizarre state of what passes for health insurance here could potentially spread that greed elsewhere, too.

Mark_Chid

thats my understanding, its certainly what my wife was told and her midwife was otherwise excellent so we saw no reason to doubt.

alek0

Unfortunately, that is not the case.

Episiotomies take longer time to heal, and are more likely to extend into third and fourth degree tears. Not to mention that with an apisiotomy there is no cahnce of intact perineum, which is of course the best option.
Below are some examples, and there are plenty more papers on this.

I would really like to hear a justification for a prcedure which "is not effective in protecting the perineum and sphincters during childbirth and may impair anal continence." There are studies (see last abstract) which estimate that risk of fecal incontinence is tripled with episiotomy compared to spontaneous tears.

Title Benefits and risks of episiotomy: a review of the English-language literature since 1980. Part II.
Author Woolley R J
Corporate Source Boynton Health Service, University of Minnesota, Minneapolis 55455, USA.
SO_JN Obstetrical & gynecological survey
Abstract Mediolateral and, to a lesser degree, midline episiotomies substantially increase the amount of blood loss at delivery; in fact, simple avoidance of episiotomy may be the most powerful means the delivery attendant has to prevent excessive intrapartum hemorrhage. The long-term morbidity of the anal sphincter damage induced by episiotomy, particularly midline, has generally been underestimated in both its frequency and severity. Other potential fetal and maternal complications of episiotomies, although rare, are numerous and serious. The overall degree of risk that accompanies this procedure could only be justified by a clear and overriding benefit, which, as discussed under "Benefits" earlier in this review, does not appear to exist.

Title Is there a benefit to episiotomy at spontaneous vaginal delivery? A natural experiment.

Author Bansal R K; Tan W M; Ecker J L; Bishop J T; Kilpatrick S J
Corporate Source Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, USA.

SO_JN American journal of obstetrics and gynecology

SO_PY Oct 1996,

SO_VO 175 p897-901,

Abstract Our purpose was to examine the association between maternal vaginal and perineal morbidity and episiotomy performed at spontaneous vaginal delivery. STUDY DESIGN: We obtained data from 17,483 consecutive spontaneous vaginal deliveries and compared the yearly rates of episiotomy, lacerations, and potential confounders with linear regression and stratified analyses. RESULTS: Between 1976 and 1994 the use of episiotomy fell significantly 86.8% to 10.4%, R2 = 0.92, p = 0.0001. This change was associated with a fall in the rate of third- and fourth-degree lacerations 9.0% to 4.2%, R2 = 0.59, p = 0.0001 and a rise in the rate of intact perinea 10.3% to 26.5%, R2 = 0.68, p = 0.0001 and vaginal lacerations 5.4% to 19.3%, R2 = 0.77, p = 0.0001. These associations held in separate analyses stratified by parity and birth weight, except for the subgroup of nulliparous women with macrosomic infants. CONCLUSION: At our institution a large reduction in the use of episiotomy in spontaneous vaginal deliveries was associated with a significant reduction in perineal trauma in all groups of women except for nulliparous women with macrosomic infants.

Title Relationship of episiotomy to perineal trauma and morbidity, sexual dysfunction, and pelvic floor relaxation.
Author Klein M C; Gauthier R J; Robbins J M; Kaczorowski J; Jorgensen S H; Franco E D; Johnson B; Waghorn K; Gelfand M M; Guralnick M S; et al
SO_JN American journal of obstetrics and gynecology
SO_PY Sep 1994,
SO_VO 171 p591-8,
Our purpose was to compare consequences for women of receiving versus not receiving median episiotomy early and 3 months post partum on the outcomes perineal pain, urinary and pelvic floor functioning by electromyography, and sexual functioning and to analyze the relationship between episiotomy and third- and fourth-degree tears. STUDY DESIGN: A secondary cohort analysis was performed of participants within a randomized clinical trial, analyzed by type of perineal trauma and pain, pelvic floor, and sexual consequences of such trauma, while controlling for trial arm.
The study was conducted in three university or community hospitals; 356 primiparous and 341 multiparous women were studied. RESULTS: Early and 3-month-postpartum perineal pain was least for women who gave birth with an intact perineum. Spontaneous perineal tears were less painful than episiotomy. Sexual functioning was best for women with an intact perineum or perineal tears. Postpartum urinary and pelvic floor symptoms were similar in all perineal groups. At 3 months post partum those delivered with an intact perineum had the strongest pelvic floor musculature, those with episiotomy the weakest. Among primiparous women third- and fourth-degree tears were associated with median episiotomy 46/47. After forceps births were removed and 21 other variables potentially associated within such tears were controlled for, episiotomy was strongly associated with third- and fourth-degree tears odds ratio +22.08, 95% confidence interval 2.84 to 171.53. Physicians using episiotomy at high rates also used other procedures, including cesarean section, more frequently.

CONCLUSION: Perineal and pelvic floor morbidity was greatest among women receiving median episiotomy versus those remaining intact or sustaining spontaneous perineal tears. Median episiotomy was causally related to third- and fourth-degree tears. Those using episiotomy at the highest rates were more likely use other interventions as well. Episiotomy use should be restricted to specified fetal-maternal indications.

SO_JN Journal of reproductive medicine

SO_PY Aug 2001,

SO_VO 46 p752-6,

Abstract To determine the risk factors for third-degree perineal tears during vaginal delivery and to investigate the relation between different types of episiotomy and the occurrence of such tears. STUDY DESIGN: This retrospective multicenter study consisted of an analysis of data from the delivery databases of the University Hospital of Vienna and Semmelweis Frauenklinic Wien between February and July 1999. The study was restricted to a sample that included all women with uncomplicated pregnancy as well as uncomplicated first and second stages of labor, gestational age > 37 weeks and a pregnancy with cephalic presentation. Women with multiple gestations, noncephalic presentation, cesarean deliveries, shoulder dystocia and gestational age < or = 37 weeks were excluded from the study. RESULTS: Among the 1,118 births, 37 women 3.3% experienced third-degree perineal tears. The use of episiotomy per se and the type of episiotomy midline as well as forceps delivery, primiparity, large infant head diameter, prolonged second stage of labor and use of oxytocin were identified as risk factors for third-degree perineal tears during vaginal delivery. When analyzing different types of episiotomy, there was approximately a sixfold-higher risk of third-degree perineal tears in women undergoing midline episiotomy as compared to mediolateral episiotomy. A stepwise logistic regression analysis revealed that episiotomy, prolonged second stage of labor and large infant head diameter remained independent risk factors for third-degree perineal tears. CONCLUSION: We found several risk factors for third-degree perineal tears. The use of midline episiotomy was associated especially with an increased risk of severe anal sphincter tears. To prevent women from long-term sequelae due to third-degree perineal tears, avoidable risk factors should be minimized whenever possible.

Title Episiotomy increases perineal laceration length in primiparous women.

Author Nager C W; Helliwell J P

SO_JN American journal of obstetrics and gynecology

SO_PY Aug 2001,

SO_VO 185 p444-50,

Abstract The aim of this study was to determine the clinical factors that contribute to posterior perineal laceration length. STUDY DESIGN: A prospective observational study was performed in 80 consenting, mostly primiparous women with term pregnancies. Posterior perineal lacerations were measured immediately after delivery. Numerous maternal, fetal, and operator variables were evaluated against laceration length and degree of tear. Univariate and multivariate regression analyses were performed to evaluate laceration length and parametric clinical variables. Nonparametric clinical variables were evaluated against laceration length by the Mann-Whitney U test. RESULTS: A multivariate stepwise linear regression equation revealed that episiotomy adds nearly 3 cm to perineal lacerations.
Tear length was highly associated with the degree of tear R = 0.86, R2 = 0.73 and the risk of recognized anal sphincter disruption. None of 35 patients without an episiotomy had a recognized anal sphincter disruption, but 6 of 27 patients with an episiotomy did P < .001. Body mass index was the only maternal or fetal variable that showed even a slight correlation with laceration length R = 0.30, P =.04. CONCLUSION: Episiotomy is the overriding determinant of perineal laceration length and recognized anal sphincter disruption.

Title Midline episiotomy and anal incontinence: retrospective cohort study.

Author Signorello L B; Harlow B L; Chekos A K; Repke J T


SO_JN BMJ

SO_PY Jan 8 2000,

SO_VO 320 p86-90,

Abstract To evaluate the relation between midline episiotomy and postpartum anal incontinence. DESIGN: Retrospective cohort study with three study arms and six months of follow up. SETTING: University teaching hospital. PARTICIPANTS: Primiparous women who vaginally delivered a live full term, singleton baby between 1 August 1996 and 8 February 1997: 209 who received an episiotomy; 206 who did not receive an episiotomy but experienced a second, third, or fourth degree spontaneous perineal laceration; and 211 who experienced either no laceration or a first degree perineal laceration. MAIN OUTCOME MEASURES: Self reported faecal and flatus incontinence at three and six months postpartum. RESULTS: Women who had episiotomies had a higher risk of faecal incontinence at three odds ratio 5.5, 95% confidence interval 1.8 to 16.2 and six 3.7, 0.9 to 15.6 months postpartum compared with women with an intact perineum. Compared with women with a spontaneous laceration, episiotomy tripled the risk of faecal incontinence at three months 95% confidence interval 1.3 to 7.9 and six months 0.7 to 11.2 postpartum, and doubled the risk of flatus incontinence at three months 1.3 to 3.4 and six months 1.2 to 3.7 postpartum. A non-extending episiotomy that is, second degree surgical incision tripled the risk of faecal incontinence 1.1 to 9.0 and nearly doubled the risk of flatus incontinence 1.0 to 3.0 at three months postpartum compared with women who had a second degree spontaneous tear.
The effect of episiotomy was independent of maternal age, infant birth weight, duration of second stage of labour, use of obstetric instrumentation during delivery, and complications of labour. CONCLUSIONS: Midline episiotomy is not effective in protecting the perineum and sphincters during childbirth and may impair anal continence.

MadMordigan

You know, you read shit like that and you wonder what the hell posesses anyone to pinch off a flesh loaf.

Corona688

Fair enough.

True. Although if there IS something to be learned from acupuncture(I think there might be), if it gives any obvious benefit, then it is possible for the medical establishment to accept it.

That wasn't quite what I intended to present.. you hit a nerve, so perhaps I was abit over the top.

Certainly there are good doctors and bad doctors. But unless I'm mistaken you are claiming that the medical profession itself is rather uniformly negative, and that I vociferously disagree with.

Two things:
1) That's a completely different branch of science, psychology rather than medicine.
2) They don't do that anymore, for the very reason that it didn't effing work, even besides the ethical problems. And it certainly didn't take them long to get rid of it, did it.

Two simple reasons:
1) If patients don't get what they want with one doctor, they can simply go somewhere else. And like I said, doctors aren't all uniformly good. With enough effort, a cooperative doctor CAN be found. If a patient can just go next door and get what he wants, it takes a person of very high moral conviction to just not shrug and say 'To hell with it. At least if I do it, I know what I'm doing'.

2) A suitably vocal patient, whether their motivations are rational or unfounded, has the ability to easily RUIN a doctor that doesn't cooperate. Patients have a LOT more rights than doctors do when it comes to medicine, and rightly so, but the situation can be easily taken advantage of. The stigma of being investigated, even if the evidence vindicates them, can easily destroy a MD's career, even if the wasted time and massive expenses don't.

eldar1011

I have to admit that I am somewhat taken aback by some of the more...uh...energetic responses.

My original post had been met with exhortations to "use my brain", accusations of being crap (dangerous crap, even) and even being compared to social Darwinism.

You'd think I was threatening to slaughter a sacred cow.

Perhaps my original post was not clear. I am not taking my wife out into the fields to have her give birth in accordance with nature. I am not advocating the destruction of the medical establishment and wholesale abandonment of all medical technology. I am not recommending that children be abandoned in the wild to be raised by wolves and let the survivors found Rome.

I am simply turning my skeptic's eye towards the routine medical intervention that has developed around childbirth. I did not expect such polarization on this topic.

Of course, there are some births that require medical intervention. Of course, we should take advantage of all the science available to us...when needed.

When one in three American births result in either caesarean or extraction via forceps or vaccum, then I can't help but wonder if medical intervention has gone too far. There are developed countries with the same medical technologies available, yet they also maintain the practice of midwifery. In *those* countries, the rates of cesarean and extraction are decidedly lower. Do American babies have bigger heads?

I do not question the benefits of medical technology. But, I *do* question the routine nature of medical intervention.

Finally, two of the more subdued replies in this thread are worth quoting:

[ September 03, 2002: Message edited by: eldar1011 ]</p>